Signing below, I am authorizing those who rely on thisĪuthorization to release my personal health information for theĮarlier of five (5) years or until my participation in the programĮnds through my cancellation, unless a shorter time period is Information, including my personal health information, to be usedįor the purposes described above. I also understand I am authorizing my personal Release it to Amgen employees, as well as to its contractors andīusiness partners, who are performing the services set forth in Providers or others who might hold my health information to only I understand that by signing this form, I authorize my Health Care Personal health information and/or for using my information toĬontact me with communications about Amgen products which haveīeen prescribed to me (for example medication reminder programs)Įxpiration, Right to Obtain a Copy and Right to Cancel Receive remuneration from Amgen in exchange for disclosing my Providers (such as pharmacies and specialty pharmacies) may I understand that certain of my Health Care Health information to Amgen, and between themselves,Īs necessary, but only for the purposes stated above in thisĪuthorization. I authorize my Health Care Providers to disclose my personal My health care plan benefits, payment limits or restrictionsĬovered by my health care plan policy, and/or my adherence to my Information from or about my medical history and general health, Pharmacy, pharmaceutical company, laboratory and/or theirĬontractor (“Health Care Provider”). Of or derived from a health care provider, health care plan, Information, in electronic or physical form, in the possession I understand that my personal health information may include any Information, including my personal health information. In order for Amgen to provide me with the services and/or programsĭescribed above, Amgen needs to collect and use my personal Materials and programs related to my condition or treatment.
To provide me with informational and promotional materials.Health care team and share with them my health information that To contact, with my permission, my doctor and the rest of my.Verification, nurse educator services, adherence program and Programs, reimbursement assistance programs, drug coverage Related to my condition or treatment (for example, co-pay Participation in Amgen ® SupportPlus program or any otherĪmgen-affiliated patient support services and activities
To operate, administer, enroll me in, and/or continue my Including my personal health information, only for the following (“Amgen”) to use and/or disclose my personal information, I authorize Amgen and its contractors and business partners Uses and Disclosure of Personal Information
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